Background and Objectives: Preventive approach in dental practice has been cited as a reason for the decline in oral diseases and as a predominant part of the service-mix of dental practices in the future. Dental faculty's knowledge and attitude toward prevention are important, since they have exceptionally important direct and indirect roles in shaping student's preventive orientation and also potentially influencing their patient's ability to take care of their teeth. Thus, this study was conducted to assess knowledge and attitudes toward preventive dental care among dental faculties and their relation to demographic and professional characteristics. Materials and Methods: A cross-sectional study was conducted among dental faculties in Bangalore city. Of 17 dental colleges, 4 were selected by simple random sampling. A total of 218 dental faculties was individually asked to complete a pretested questionnaire. The questionnaire requested information on dental faculty's demographic and professional characteristics and their knowledge and attitudes toward preventive dental care. Descriptive, Chi-square tests, and ANOVA were used to analyze the data. Results: The highest knowledge was seen among dental faculties regarding prevention of malocclusion (3.51 ± 1.02) followed by oral cancer (2.95 ± 1.09) and periodontal diseases (2.86 ± 1.02). The least knowledge was seen for the prevention of caries (2.63 ± 1.35). The most positive attitudes regarding preventive dentistry was characterized as being essential (6.34 ± 1.05), useful (6.32 ± 1.07) and valuable (6.27 ± 1.00). Statistically significant differences were found in relation to knowledge and attitudes for all demographic and professional characteristics except for gender and Department of Teaching. Conclusion: Dental faculty seems to have differing levels of knowledge regarding oral diseases with positive attitudes seen regarding preventive dentistry. Continuing education activities and placing emphasis on prevention-related research are recommended.

Oral diseases continue to be among the most prevalent problems in our society, despite the importance of oral health to personal overall health and well-being. [1] Most established oral diseases such as dental caries, periodontal diseases, malocclusion, and oral cancer are irreversible, will last for a lifetime and have an impact on general health and quality of life. [2] Oral diseases affect children, adults, and families across the world every day, although they are nearly 100% preventable. [3] Thus, knowledge about the oral disease is important, which can act as a major vehicle for maintaining the oral well-being. [2]

Clinical and public health research have shown a number of individual, professional, and community preventive measures which are effective in preventing most oral diseases. [3] The reorientation of oral health services toward prevention and health promotion is one of WHO's priority action areas for the continuous improvement of oral health. [4] However, emphasis on primary prevention of oral diseases poses a considerable challenge for many countries, particularly the developing countries and countries with economies and health systems in transition. [3]

India, a developing country faces many challenges in rendering oral health needs. Many people cannot avail dental facilities due to inaccessibility, financial constraints, and stagnation of public dental healthcare services. As preventive measures are simple, effective, and economical, this entails the dental health professional to adopt a more practical approach to achieve prevention of oral diseases. [2]

Dental faculty's knowledge and attitude toward prevention can provide a framework for their professional work. With the exponential growth of dental science, they need to update their practices according to the best available scientific evidences, since they are the ones who convey evidence-based knowledge of oral health care to their students and patients. [4]

Health beliefs and attitudes of dental students, as future dental health professionals, not only affect their oral self-care habits but also potentially influence their patient's ability to take care of their teeth and shape the public's oral health education level. [5] Although enhancing the knowledge of students is very important to this process, dental faculty's attitude toward prevention, known to be a component of the "hidden curriculum," is an influential factor. [6]

In order to train a prevention-oriented dental workforce, educational institutions should respond to growing evidence of the value of appropriate use of prevention and nonsurgical treatment. It has been suggested that improvements in applying preventive measures can be achieved by creating supporting policies for application parallel with training of a prevention-focused dental workforce. In the latter, teaching faculties in dental institutions carry the main responsibility. [6] Thus, via their knowledge and attitudes toward prevention, dental faculties have exceptionally important direct and indirect roles in shaping student's preventive orientation. [5]

A need thus exists to develop sustainable prevention-oriented approach, especially in countries with developing health care systems. [7] Although some studies have explored knowledge and attitudes concerning prevention among medical faculties and dentists, orientation regarding preventive aspects is a rarely investigated field among dental faculties. In a study of dental educators' own oral health behavior, it was shown that there is room for improvement in this area. [4],[5] Thus, the aim of the present study was to assess knowledge and attitudes toward preventive dental care among dental faculty and their relation to demographic and professional characteristics in Bangalore city.

Materials and Methods

Study subjects and data collection

This was a cross-sectional study done over a period of 3 months from June to August 2013. List of dental faculty was obtained from the website of Rajiv Gandhi University Of Health Sciences, which served as a sampling frame. To obtain a representative sample of dental faculty working in a total of 17 dental colleges in Bangalore city, a simple random sampling approach was used. Four dental colleges were selected randomly for the purpose of the study. Faculty of Master of Dental Surgery (MDS) in the Department of Prosthodontics, Periodontics, Conservative Dentistry and Endodontics, Orthodontics, Pedodontics, Oral Medicine and Radiology, Oral Surgery, and Oral Pathology were included in the study whereas Faculty of MDS in the Department of Public Health Dentistry was excluded.

Sample size calculation

The sample size was calculated based on total of 850 dental faculties in 17 dental colleges in Bangalore city. With the prevalence of knowledge (79%) from the pilot study, using confidence level of 95% and design effect 1, sample size was estimated to be of 197 participants. Considering 10% nonresponse rates 218 was taken as final sample size.

Permission was obtained from the concerned authorities and the principal of the respective colleges. Ethical clearance was also obtained from the institutional review board. The dental faculties on the day of data collection were individually asked to voluntarily complete a pretested anonymous questionnaire. Majority of the filled questionnaires were collected back immediately on the day of data collection. Those faculties who said they were busy on the day of data collection and for a few days, a 1-week time was given, and questionnaires were then collected accordingly.

Development of the questionnaire

Questionnaire used in this study was developed from the previous literature [4],[6],[7],[8],[9],[10],[11],[12] designed in English, which was validated, and modifications were then made accordingly before the final questionnaire was administered. A pilot study was conducted on 30 subjects who were selected randomly, to pretest the data collection methods and for the clarity and meaning of the questions. The pilot study subjects were not included in the main study. To estimate the reliability of the questionnaire used in this study, a questionnaire was given twice to the respondents, first on the day of the pilot study and then again after 1-week to ensure reliable answers. The co-efficient of reliability were calculated using Cronbach's alpha (0.81) that indicated good reliability.

Questionnaire had five parts: Part one consisted of informed consent and demographic information of the dental faculty such as age, gender, Department of Teaching, and years of experience in teaching. Name was not recorded to maintain the confidentiality. Part two consisted information on dental faculty's participation in continuing education courses on prevention of oral diseases and their professional reading habits. Part three recorded information regarding dental faculty's familiarity with the field of Dental Public Health (DPH). The faculties were asked to express how well they were acquainted with the DPH field and how much work experience in teaching research and planning they had in the field.

Part four assessed the knowledge of dental faculty regarding preventive dental care. Twenty statements regarding prevention of dental caries, periodontal diseases, oral cancer, malocclusion, and dental visit assessed the respondent's knowledge of prevention. Responses were recorded on a 5-point Likert scale, ranging from 0 to 4, that is, from "strongly disagree" to "strongly agree". Part five assessed attitudes of dental faculty toward preventive dentistry. Using the semantic differential method, a set of 6 pairs of bipolar adjectives, which describe preventive dentistry, was designed. The respondents were asked to describe their attitudes by choosing one option from a Likert scale, ranging 1-7; the higher the score, the more positive the attitude.

Statistical analysis

Descriptive statistics included means and standard deviation of the respondent's knowledge and attitude scores. Statistical significances of the differences between the subgroups to be compared were evaluated using the Chi-square test for frequencies and ANOVA for mean values.

Results

The participants presented with a mean age of 35.3 years. Of 218 participants, 52.3% were males and 47.7% females. About 16.5% participants were from the Department of Periodontics; 13.3% from conservative dentistry and endodontics; 13.3% from orthodontics; 12.3% from prosthodontics; 12.0% from pedodontics; 12.0% from oral medicine and radiology; 10.5% from oral surgery; and 10.1% from oral pathology. Majority of dental faculties were designated readers, based on their years of experience in teaching [Table 1].

Majority of the respondents had participated in continuing education courses within last year (72.5%) whereas only 21.1% participated 2-5 years ago and 5.5% had participated >5 years ago. Majority of the dental faculties read both specialty and nonspecialty journals. Three-fourth of the respondents was familiar with the field of DPH [Table 2].

Table 2: Distribution of respondents by selected professional characteristics (n=218)

Dental faculties knowledge of preventive dental care in relation to caries was the most accurate regarding the role of sugar consumption (mean ± standard deviation: 3.47 ± 0.78) and sealants (3.41 ± 0.64) followed by the role of water fluoridation (2.97 ± 1.00). The least accurate knowledge was seen with respect to the superiority of the use of fluoride toothpaste over brushing technique (1.35 ± 1.25) and use of sharp explorer in damaging enamel rods while examining initial carious lesion (1.96 ± 1.42). The dental faculty exhibited more knowledge about association of periodontal disease with cardiovascular disease, low birth weight, and diabetes (3.11 ± 0.91) whereas it was minimal for the use of fluoride in promoting periodontal health and preventing dental caries (2.50 ± 1.03) [Table 3].

Table 3: Level of knowledge of preventive dental care in relation to dental caries and periodontal disease among dental faculties

In relation to oral cancer, dental faculties were more aware about the importance of early diagnosis (3.43 ± 0.62), health education (3.31 ± 0.87), screening (3.19 ± 0.91), and risk factors (3.04 ± 0.88) whereas they were unaware about the diagnosis of oral cancer in older age groups (1.77 ± 1.20). Dental faculties were found more knowledgeable about the use of space maintainer (3.67 ± 0.58), care of deciduous dentition (3.45 ± 0.71), etiology (3.56 ± 0.55), and risk factors (3.36 ± 0.62) of malocclusion. Majority of the respondents considered regular dental visits to be important for preventing oral diseases [Table 4].

When comparing overall knowledge of preventive dental care, statistically significant differences were found for knowledge related to prevention of caries, periodontal diseases, oral cancer, and malocclusion (P < 0.001). Dental faculties considered prevention of malocclusion to be the most important (3.51 ± 1.07), followed by oral cancer (2.95 ± 1.09) and periodontal diseases (2.86 ± 1.02). The least knowledge was seen for the prevention of dental caries (2.63 ± 1.35) [Table 5]. Statistically significant differences were found between preventive knowledge of all these oral diseases except between periodontal diseases and oral cancer using Tukey's Post-hoc test [Table 5]a].

Most positive attitudes were seen by the respondents who characterized preventive dentistry as essential (6.34 ± 1.05), useful (6.32 ± 1.07), and valuable (6.27 ± 1.00) to the community. The lesser positive attitudes were found for some dental faculty-related aspects, indicating that preventive dentistry was difficult for faculty to practice (5.42 ± 1.66) and less reputable for faculty (5.87 ± 1.28) [Table 6].

As to the categories of dental faculty's level of knowledge of preventive dental care, 81.2% fell into the high category, 18.8% medium, and none in the low category. For further analysis, respondents belonging to high level of knowledge were considered. Statistically significant differences were found for dental faculties' knowledge and participation in continuing education courses (P < 0.001), their professional reading habits (P < 0.001) and familiarity with DPH (P < 0.001). No significant differences were found with respect to gender, Department of Teaching, and years of experience. Of all the respondents, 93.6% belonged to the high level of positive attitudes toward preventive dental care, while 5.5% demonstrated a medium and 0.92% a low level of positive attitudes. For further analysis, participants with a high level of positive attitudes were considered. Statistically significant differences were found when comparing dental faculties attitude in relation to years of experience in teaching (P < 0.05), participation in continuing education courses (P < 0.001), their professional reading habits (P < 0.001) and familiarity with DPH (P < 0.001). No significant differences were found with respect to gender and Department of Teaching [Table 7].

Table 7: Number and percentages of dental faculty (n=218) belonging to the categories of high levels of their knowledge of and attitudes toward preventive dental care, according to their demographic and professional characteristics

Preventive oral health education is in transition stage in India. [13] Despite the current emphasis on prevention in dental education, and although there have been some studies of the preventive knowledge of dental students, dentists, and dental hygienists, very few studies have focused on the orientation of preventive aspects among dental faculty. [5] To our knowledge, no study exists on the preventive knowledge and attitude of dental faculty in Bangalore city.

In the present study, the highest knowledge was seen among dental faculties regarding prevention of malocclusion followed by oral cancer and periodontal diseases. The least knowledge was seen for the prevention of caries. This indicates that despite, dental caries being, one of the most common oral diseases affecting individuals, there is a need for dental institutions to focus more on caries prevention programs in order to increase the knowledge of dental faculty.

With respect to dental caries, the present results indicate that the majority of dental faculties have acquired adequate knowledge regarding the influence of sugar, sealants, and water fluoridation on dental caries; this is in accordance with the findings of a similar study by Ghasemi etal. [4] and Khami etal. [6] On the other hand, deficiencies were evident in the knowledge of the role of fluoride in caries prevention in comparison to brushing technique and of some aspects of caries initiation and progression, Similar deficiencies in this respect have recently been reported for Iranian dental students, [9] dentists, [4] and dental educators. [6] This is contrary to the opinion of a group of experts that fluoride plays an important role in caries prevention. [4] These may stem from a lack of attention paid to the role of fluoride in caries prevention and cariology in dental education, which calls for putting more emphasis on these subjects in dental curricula and continuing education.

In our study, majority of the dental faculties knew about the signs and symptoms of periodontal diseases, association of periodontal diseases with systemic diseases, importance of using toothbrush and dental floss and rinsing after food with water to prevent periodontal diseases. This is in accordance with the findings of a similar study by Rabiei etal. [7] The lesser knowledge was seen regarding the use of fluoride in promoting periodontal health. This is contrary to the opinion of many researchers considering fluoride as, not only important in preventing caries but also in promoting periodontal health. [9]

In relation to oral cancer, the present results indicate that the dental faculty considered early diagnosis, health education, and screening as an important tool in the prevention of oral cancer. Majority of them were aware of the risk factors for oral cancer while on the other hand, deficiencies were evident in the knowledge regarding the diagnosis of oral cancer in older age groups. These findings are consistent with the similar studies done by Clovis etal., [8] Carter and Ogden, [14] and Pakfetrat etal. [15] Regarding prevention of malocclusion, majority of respondents knew about the adverse effects of oral habits on the future alignment of teeth, importance of space maintainer, deciduous teeth, and timely restoration of carious teeth.

Attitudes are influenced by beliefs and values, personal needs, and behavior. [4] Overall, the dental faculty in this study showed positive attitudes toward preventive dentistry, characterized as being essential, useful, and valuable. This is a positive indication that they are willing to become involved in preventive care. On the other hand, they find preventive dentistry difficult to practice and personally disreputable. Similar findings have been reported in a study by Ghasemi etal. [4] and Khami etal. [6] These attitudes among dental faculties may originate from their lack of importance given to prevention during their training and education and perceived barriers in their practice as inadequate reimbursement, time limitation because of high demand for curative care, and unwillingness of patients to pay for prevention.

According to the results of the present study, no gender differences were seen among dental faculties for prevention-oriented knowledge and attitudes, whereas a study conducted by Ghasemi etal. [4] and Khami etal. [6] reported more positive attitudes among female dental faculties as compared with their male counterpart. A study was done by Khami etal., [6] where the faculties working in the Department of Pedodontics, Conservative Dentistry and Endodontics, and Periodontics had more extensive knowledge of prevention, while in our study no significant differences were seen in relation to Department of Teaching for prevention-oriented knowledge and attitudes. Thus, from our study, it can be expected that dental faculty, regardless of their discipline, possesses basic knowledge of prevention and positive attitudes toward preventive dentistry.

In relation to years of experience in teaching, no significant differences were found among dental faculties for preventive knowledge and positive attitudes were seen toward preventive dentistry which was statistically significant. The significant results in our study may be due to more number of respondents with 4-8 years of experience in teaching.

Significant differences were found among dental faculties when knowledge and attitude scores were compared to their participation in continuing education courses and professional reading habits. This is in contrast to a study done by Ghasemi etal. [4] on dentists where no significant differences were found for knowledge and attitude scores when such parameters were assessed. This indicates that, in the present study, activity in continuing education had an impact on dental faculty's knowledge and attitude toward prevention. Thus, to meet the demand for producing highly competent dental faculty, more evidence-based program on prevention should be integrated into dental education during graduation as well as postgraduation and emphasis should be placed on continuing education courses for dental faculties. [16]

Dental faculty who were familiar with the field of DPH reported high level of knowledge and positive attitudes toward preventive dentistry. These findings together with results from a study by Khami etal., [6] show that familiarity with DPH can be considered an indicator of dental faculty's knowledge and attitudes toward prevention, and it emphasizes the importance of assessing knowledge and attitudes in dental education.

As nonresponses, misconceptions, and errors are common with surveys using a self-administered questionnaire; these should be minimum in our survey, since the respondents were highly educated health professionals. Faculty of public health dentistry department was also excluded from our study, as this might influence our results indicating high level of knowledge, since it mainly deals with prevention-related research.

In interpreting the findings of the present study, it is important to acknowledge possible limitations. The cross-sectional design allows investigation of potential links between the level of knowledge and attitude; causality clearance, however, requires longitudinal studies. There is a possibility of social desirability bias wherein the respondents over or under report the knowledge and attitudes because dental faculty tend to be more interested in the topics of the questionnaire related to their specialty. Furthermore, some of the faculties gave back the filled questionnaire after 1-week; this may lead to the possibility of reporting bias. As practice was not included in the study, prevention-oriented knowledge and attitudes found may not, however, relate to dental faculty's everyday professional activity.

Conclusion and Recommendations

Our study concluded that the dental faculty in Bangalore had good knowledge of preventive dental care which was significantly different with respect to oral diseases and had positive attitudes toward preventive dentistry. Reduction in oral diseases and increasing the availability and adoption of appropriate preventive procedures will not occur without the adequate knowledge of dental faculty as they are involved in training the future dental professionals. This can only be achieved if dental faculties are involved in continuing education activities and placing emphasis and support on prevention-related research. Institutional changes to assure adequate reimbursement for age-appropriate oral disease prevention strategies should also be considered.

The following measures may be taken to improve the dental faculty's knowledge about preventive dental care and to expand their role in the same.

Including preventive dentistry topics for students across all 4 years of undergraduate and 3 years of postgraduation irrespective of the specialty, so that these students as future dental faculty assume a greater role in oral health related activities

Developing and testing the outcomes of curriculums, designed to increase the understanding of the importance of signs and symptoms of oral diseases and their prevention

Continuing education activities specially designed for dental faculty, together with increasing emphasis on prevention-related research should be applied to enhance knowledge of and positive attitude toward prevention

More number of preventive dentistry articles to be published in journals